Nokea
A client has consented to have a central venous catheter placed. The best position in which to place the client is the Trendelenburg position. The reason is that the Trendelenburg position:
- A. Allows the physician to visualize the subclavian vein
- B. Reduces the possibility of air embolism
- C. Reduces the possibility of hematoma formation
- D. Makes the procedure more comfortable for the client
Correct Answer: B
Rationale: The Trendelenburg position reduces air embolism risk by increasing central venous pressure and distending veins for easier catheter insertion.
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A client's transfusion of packed red blood cells has been infusing for 2 hours. She is complaining of a raised, itchy rash and shortness of breath. She is wheezing, anxious, and very restless. The nurse knows these assessment findings are congruent with:
- A. Hemolytic transfusion reaction
- B. Febrile transfusion reaction
- C. Circulatory overload
- D. Allergic transfusion reaction
Correct Answer: D
Rationale: A hemolytic transfusion reaction would be characterized by fever, chills, chest pain, hypotension, and tachypnea. Fever, chills, and headaches are indicative of a febrile transfusion reaction. Circulatory overload is manifest by dyspnea, cough, and pulmonary crackles. Urticaria, pruritus, wheezing, and anxiety are indicative of an allergic transfusion reaction.
A 49-year-old obese woman has been admitted to the general surgery unit with choledocholithiasis. As the nurse is admitting her to the unit, she states, 'The doctor said I have stones that need to be removed; where are they?' The nurse knows that the best explanation for this is to tell her that:
- A. There are stones present in her gallbladder
- B. There are stones present in her kidneys
- C. There are stones present in her common bile duct
- D. There are no stones, but her gallbladder is irritated and caused her nausea, vomiting, and pain
Correct Answer: C
Rationale: Cholelithiasis is the correct term used to describe the presence of stones in the gallbladder. Nephrolithiasis, or renal calculi, is the correct term used to describe the presence of stones in the kidney. Choledocholithiasis is the correct term used to describe the presence of stones in the common bile duct. Cholecystitis is the correct term used to describe inflammation of the gallbladder and can be associated with cystic duct obstructions from impacted stones.
The nurse is observing the ambulation of a client recently fitted for crutches. Which observation requires nursing intervention?
- A. Two finger widths are noted between the axilla and the top of the crutch.
- B. The client bears weight on his hands when ambulating.
- C. The crutches and the client's feet move alternately.
- D. The client bears weight on his axilla when standing.
Correct Answer: D
Rationale: Bearing weight on the axilla can cause nerve damage (e.g., brachial plexus injury); crutches should support weight on the hands.
A female client who has chronic obstructive pulmonary disease (COPD) has presented in the emergency department with cough productive of yellow sputum and increasing shortness of breath. On room air, her blood gases are as follows: pH 7.30 mm Hg, PCO2 60 mm Hg, PO2 55 mm Hg, HCO3 32 mEq/L. These arterial blood gases reflect:
- A. Compensated respiratory acidosis
- B. Normal blood gases
- C. Uncompensated metabolic acidosis
- D. Uncompensated respiratory acidosis
Correct Answer: D
Rationale: Low pH, high PCO2, and normal HCO3 indicate uncompensated respiratory acidosis, reflecting acute exacerbation of COPD.
A client has been taking lithium 300 mg po bid for the past two weeks. This morning her lithium level was 1 mEq/L. The nurse should:
- A. Notify the physician immediately
- B. Hold the morning lithium dose and continue to observe the client
- C. Administer the morning lithium dose as scheduled
- D. Obtain an order for benztropine (Cogentin)
Correct Answer: C
Rationale: There is no need to phone the physician because the lithium level is within therapeutic range and because there are no indications of toxicity present. There is no reason to withhold the lithium because the blood level is within therapeutic range. Also, it is necessary to give the medication as scheduled to maintain adequate blood levels. The lab results indicate that the client's lithium level is within therapeutic range (0.2-1.4 mEq/L), so the medication should be given as ordered. Benztropine is an antiparkinsonism drug frequently given to counteract extrapyramidal symptoms associated with the administration of antipsychotic drugs (not lithium).